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Dissecting aneurysm of the ascending aorta during the third trimester of pregnancy with cardiac tamponade
COMMUNICATIONS IN BRIEF
Dissecting aneurysm of the ascending aorta during the third trimester of pregnancy with cardiac tamponade JOHN
A.
HERMAN,
Department of Medicine, Montefiore-Morrisania New York, New York
Dissecting aneurysm of curring during pregnancy if not quickly recognized leads cases
to death in nearly treated medically.
bruit were present. The fundus of the uterus was midway between the umbilicus and the xiphoid. Carotid, radial, and femoral pulses were equal. The neurologic examination was normal. The urine was 4+ albumin, hyaline casts, with 5 red blood cells per high-power field, complete blood count, 16,000 white blood cells per millimeter, normal differential, hematocrit 40 per cent. Electrocardiogram, slight left ventricular hypertrophy with nonspecific ST segment depression. At midnight the patient was given 10 mg. of intramuscular metaraminol which restored the blood pressure from essentially zero to 150/120 mm. Hg. At 2:00 A.M. 0.8 mg. of digoxin and 100 mg. of Seconal were given intramuscularly. At 3:00 A.M., the membranes ruptured. At 6:00 A.M., the patient complained of girdling abdominal pain and said she was going into labor. Blood pressure was 1 lo/80 mm. Hg without vasopressors. At 6: 15 A.M., she let out a gasp, appeared to have a seizure, and died. Postmortem cesarean section was not attempted. At autopsy, the pericardial sac was distended with 400 ml. of blood and clots. The heart showed left ventricular hypertrophy. The aortic valve was of normal circumference and the cusps were normal. Three centimeters above the aortic valve was an area of linear rupture of the endothelium extending through the adventitia and opening externally into the pericardial sac. The coronary arteries, like the aorta, were free of significant atheromatous change. The uterus contained a 2,000 gram fetus. The head was engaged and the cervix was 4 cm., which demonstrated that the patient was actually in labor. On histologic examination, sections of the aorta stained with Verhoeff and G6m6ri stains revealed interruption and destruction of elastic fibers and formation of cystic spaces (Fig. 1) which contained a basophilic material stained by periodic acid-Schiff reagent. The pathologic diagnoses were cystic medionecrosis of the ascending aorta, rupture of the aorta with hemopericardium, and myocardial hypertrophy.
M.D.
Affiliation,
the thoracic aorta ocis a catastrophe which, and treated surgically, 100
per
cent
of
the
The patient was a 36-year-old gravida vii, para v, with 2 stillbirths. She was a Negro female presenting in the seventh month of pregnancy with unobtainable pulse or blood pressure. The prenatal course was uncomplicated. The afternoon of admission while sitting at a desk, she became dizzy, nauseated, and fainted. She awoke a few minutes later with an oppressive sensation across her upper chest. The patient had a 6 year history of hypertension with pressures as high as 190/130 mm. Hg. She had had toxemia of pregnancy 6 years ago and again one year prior to admission with loss of the fetus in the third trimester. Serologic tests for syphilis were negative. The blood pressure, which was unobtainable rose to 150/120 mm. Hg after on admission, 10 mg. of intramuscular metaraminol (Aramine). The pulse was 120 per minute. Apart from pressure over the chest and dyspnea, she felt well. Findings were narrowing of the retinal arterioles, crepitant and moist rales at the lung bases, an enlarged heart 2 cm. lateral to the midclavicular line, and loud snapping heart sounds at the base with a soft blowing Grade 3/6 holodiastolic murmur at the aortic area transmitted to the neck and down the left sternal border. This murmur was not present on previous admissions. A protodiastolic gallop and low-pitched systolic ejection
Dissecting aneurysm of the thoracic aorta in pregnancy is not as rare as might be expected. Of 580 cases of dissection of the aorta,1 20 per cent were found in people under the age of 282
Communications
Fig. 1. High-power photomicrograph showing cystic spaces and disruption in the outer third of the media of the thoracic aorta.
40. Of thrsr 141 cases, 49 were women and 24 were pregnant, 20 in the third trimester. Hence, if WC consider women under 40 who have disserting aneurysm, 50 per cent of them will be pregnant and most of them in the third trimester of pregnancy. About 50 cases of dissecting aneurysm in pregnancy have been reported in the English literature up to 1964. The cast described fits in well with what we know of dissecting aneurysm of the thoracic aorta. The patit,nt had cystic medionecrosis of the aorta which allowed the development of cleavage planes by the superimposed stresses of hypertension and the increased blood volume and cardiac. output of the third trimester of pregnancy. She presented in shock which would makr one think of placenta previa, abruptio pl~N:tYlt;K-, or ruptured uterus, hut she had a histtrry XIKI siqrls that warned of dissecting
in
brief
of the plasti(. fil)f ‘!
283
F
an~urysrn and impending c.ardiac tarltpoI]ade. Specifically, she had an aortic diastolic Inurmur that had not been prrsent on previotls admissions, a negative serologic test for syphilis, and shock without signs of an acute abdom’n. It is evident that the chest pain and syncop~ recurred at the onset of dissection and that the diastolic nlurmur was caused by distortion of the aortic valve ring secondary to the dissecting hrtnatoma. The murmur prcsqed rupture of I he h~matoma into the pcricardial sac with tarnponad~~ and dcsth.
.L\ case is presented of a 36-year-old female with dissecting aneurysm of the ascending aorta during the third trimester of prpgna>\cv with cardiac tamponade and death. The relative frequency of this ~.ata>t!~ol>he in l)rt:jr;n;mt women is discussed. It is strPssrd that any worn;m in I he third
284
Communications
in brief
trimester of pregnancy history of hypertension, basal diastolic murmur,
in shock, who has a long the recent onset of a and a negative sero-
logic reaction for syphilis should be considered as having dissecting aneurysm of the ascending thoracic aorta. REFERENCE
1.
Schnitker, M. A., and Bayer, Inter. Med. 20: 486, 1944. 1825 Lincoln San Rafael,
C.
A.:
Ann.
Avenue California
Rupture of the liver associated with toxemia of pregnancy QUENTIN Dejartment Polk
County
C.
DEHAAN,
of Obstetrics
Hospital,
M.D. and
Bartow,
Gynecology, Florida
R u P T u R E of the liver associated with toxemia of pregnancy occurs rarely, but is probably the gravest complication that can occur during pregnancy. Twenty-one cases have been recorded in the medical literature since Abercrombie’ first described the entity in 1844. The last reported case was by Pavlic and T0wnsend.s This is a 37-year-old Negro female, para 2-O-l-2, who was seen because of upper abdominal pain, nausea, and shortness of breath. Her last normal ueriod had occurred in December. 1961, and she was due in early September, 1962. The first prenatal clinic visit was made the first week in April, at which time she was found to be approximately 5 months pregnant and normotensive. She was not seen again until the first week of May, at which time her blood pressure was 190/110 and was associated with albuminuria and swelling of the lower extremities. Rauwolfia serpentina (Raudixin) 100 mg., was administered three times daily, and she was advised to report to the Polk County Hospital for definitive care. She failed to keep this appointment. On the afternoon of May 12, at 2:00 P.M., she noted a sudden onset of acute incapacitating, upper abdominal pain which radiated through to the back and was associated with nausea, weakness, and some shortness of breath. She made an effort to meet the problem for one hour at home, taking several milk of magnesia tablets without relief. She then called her local physician who saw her at home. She was doubled over with pain and unable to walk. She was given meperidine hydrochloride (Demerol) 100 mg., at this 1
time. The diagnostic impression was possible corunary occlusion, or an acute biliary colic. After approximately 2 hours, she was referred to the Polk Countv Hosnital. Examination 3 hours after the onset of pain revealed the blood pressure to be 240/150, and the patient in acute distress. Right upper quadrant pain and tenderness were noted. The fundus of the uterus was a fingerbreadth above the umbilicus. No fetal heart tones were heard. Meoeridine hvdrochloride. 100 me.. --I aminophylline //z grains, atropine l&o grab, and resernine (Seroasil) 2.5 mg. were .eiven. She . >., was placed in an oxygen ten; in se&-Fowler’s position. The electrocardiogram was normal. Approximately 4 hours after admission, the blood pressure suddenly fell to 90/60. She was placed in Trendelenburg position and dextran solution was given intravenously. Examination revealed a soft abdomen. The fetal skull could be palpated readily and exhibited a “ping-pang ball” sensation. The diagnosis of ruptured uterus was entertained. Pelvic examination revealed the cervix to be 2 cm. dilated. Small parts were felt. There was no bleeding. She was taken to the x-ray department for a flat plate of the abdomen. Before she could be explored, and while still on the x-ray table, the blood pressure was lost. In spite of transfusion by way of the femoral vein, she died. At autopsy, the peritoneal cavity contained approximately 1,500 C.C. of blood mixed with clots. The site of bleeding was a rupture in the capsule of the right lobe of the liver, thr capsule having been elevated approximately 2 cm. by a massive hematoma. The uterus was intact. Microscopic sections of the liver showed periportal necrosis. Sections of the kidney revealed thickening of Bowman’s capsule. The uterus displayed nothing remarkable other than a small fetus. The uteroplacental junction was intact. This case represents ported in the medical Radernaker,” the chain
the twenty-second reliterature. According to of events is infarction,
peripheral hypervascularization, vessel rupture, intrahepatic hemorrhage, tissue rupture, subcapsular hematoma, capsule perforation, hemoperitoneum, peritonitis, and death. The role of toxemia is evident by a pre-existing liver lesion of toxemia. Common factors noted in cases reported are multiparity (only one primigravida) , average age of 33 years in a patient with toxemia of pregnancy, and the right lobe of the liver is usually involved. Treatment is successful only in those cases which are surgically explored. The 6 survivals recorded in the literature were surgically explored with a preoperative diagnosis of rupturr of the uterus or abruptio placentae. If the diagnosis is suspected prior to death, immediat~~ surgical intervention may be lifesaving. Digital pressure on thr portal vein in thr region of the*
Dissecting aneurysm of the ascending aorta during the third trimester of pregnancy with cardiac tamponade JOHN
A.
HERMAN,
Department of Medicine, Montefiore-Morrisania New York, New York
Dissecting aneurysm of curring during pregnancy if not quickly recognized leads cases
to death in nearly treated medically.
bruit were present. The fundus of the uterus was midway between the umbilicus and the xiphoid. Carotid, radial, and femoral pulses were equal. The neurologic examination was normal. The urine was 4+ albumin, hyaline casts, with 5 red blood cells per high-power field, complete blood count, 16,000 white blood cells per millimeter, normal differential, hematocrit 40 per cent. Electrocardiogram, slight left ventricular hypertrophy with nonspecific ST segment depression. At midnight the patient was given 10 mg. of intramuscular metaraminol which restored the blood pressure from essentially zero to 150/120 mm. Hg. At 2:00 A.M. 0.8 mg. of digoxin and 100 mg. of Seconal were given intramuscularly. At 3:00 A.M., the membranes ruptured. At 6:00 A.M., the patient complained of girdling abdominal pain and said she was going into labor. Blood pressure was 1 lo/80 mm. Hg without vasopressors. At 6: 15 A.M., she let out a gasp, appeared to have a seizure, and died. Postmortem cesarean section was not attempted. At autopsy, the pericardial sac was distended with 400 ml. of blood and clots. The heart showed left ventricular hypertrophy. The aortic valve was of normal circumference and the cusps were normal. Three centimeters above the aortic valve was an area of linear rupture of the endothelium extending through the adventitia and opening externally into the pericardial sac. The coronary arteries, like the aorta, were free of significant atheromatous change. The uterus contained a 2,000 gram fetus. The head was engaged and the cervix was 4 cm., which demonstrated that the patient was actually in labor. On histologic examination, sections of the aorta stained with Verhoeff and G6m6ri stains revealed interruption and destruction of elastic fibers and formation of cystic spaces (Fig. 1) which contained a basophilic material stained by periodic acid-Schiff reagent. The pathologic diagnoses were cystic medionecrosis of the ascending aorta, rupture of the aorta with hemopericardium, and myocardial hypertrophy.
M.D.
Affiliation,
the thoracic aorta ocis a catastrophe which, and treated surgically, 100
per
cent
of
the
The patient was a 36-year-old gravida vii, para v, with 2 stillbirths. She was a Negro female presenting in the seventh month of pregnancy with unobtainable pulse or blood pressure. The prenatal course was uncomplicated. The afternoon of admission while sitting at a desk, she became dizzy, nauseated, and fainted. She awoke a few minutes later with an oppressive sensation across her upper chest. The patient had a 6 year history of hypertension with pressures as high as 190/130 mm. Hg. She had had toxemia of pregnancy 6 years ago and again one year prior to admission with loss of the fetus in the third trimester. Serologic tests for syphilis were negative. The blood pressure, which was unobtainable rose to 150/120 mm. Hg after on admission, 10 mg. of intramuscular metaraminol (Aramine). The pulse was 120 per minute. Apart from pressure over the chest and dyspnea, she felt well. Findings were narrowing of the retinal arterioles, crepitant and moist rales at the lung bases, an enlarged heart 2 cm. lateral to the midclavicular line, and loud snapping heart sounds at the base with a soft blowing Grade 3/6 holodiastolic murmur at the aortic area transmitted to the neck and down the left sternal border. This murmur was not present on previous admissions. A protodiastolic gallop and low-pitched systolic ejection
Dissecting aneurysm of the thoracic aorta in pregnancy is not as rare as might be expected. Of 580 cases of dissection of the aorta,1 20 per cent were found in people under the age of 282
Communications
Fig. 1. High-power photomicrograph showing cystic spaces and disruption in the outer third of the media of the thoracic aorta.
40. Of thrsr 141 cases, 49 were women and 24 were pregnant, 20 in the third trimester. Hence, if WC consider women under 40 who have disserting aneurysm, 50 per cent of them will be pregnant and most of them in the third trimester of pregnancy. About 50 cases of dissecting aneurysm in pregnancy have been reported in the English literature up to 1964. The cast described fits in well with what we know of dissecting aneurysm of the thoracic aorta. The patit,nt had cystic medionecrosis of the aorta which allowed the development of cleavage planes by the superimposed stresses of hypertension and the increased blood volume and cardiac. output of the third trimester of pregnancy. She presented in shock which would makr one think of placenta previa, abruptio pl~N:tYlt;K-, or ruptured uterus, hut she had a histtrry XIKI siqrls that warned of dissecting
in
brief
of the plasti(. fil)f ‘!
283
F
an~urysrn and impending c.ardiac tarltpoI]ade. Specifically, she had an aortic diastolic Inurmur that had not been prrsent on previotls admissions, a negative serologic test for syphilis, and shock without signs of an acute abdom’n. It is evident that the chest pain and syncop~ recurred at the onset of dissection and that the diastolic nlurmur was caused by distortion of the aortic valve ring secondary to the dissecting hrtnatoma. The murmur prcsqed rupture of I he h~matoma into the pcricardial sac with tarnponad~~ and dcsth.
.L\ case is presented of a 36-year-old female with dissecting aneurysm of the ascending aorta during the third trimester of prpgna>\cv with cardiac tamponade and death. The relative frequency of this ~.ata>t!~ol>he in l)rt:jr;n;mt women is discussed. It is strPssrd that any worn;m in I he third
284
Communications
in brief
trimester of pregnancy history of hypertension, basal diastolic murmur,
in shock, who has a long the recent onset of a and a negative sero-
logic reaction for syphilis should be considered as having dissecting aneurysm of the ascending thoracic aorta. REFERENCE
1.
Schnitker, M. A., and Bayer, Inter. Med. 20: 486, 1944. 1825 Lincoln San Rafael,
C.
A.:
Ann.
Avenue California
Rupture of the liver associated with toxemia of pregnancy QUENTIN Dejartment Polk
County
C.
DEHAAN,
of Obstetrics
Hospital,
M.D. and
Bartow,
Gynecology, Florida
R u P T u R E of the liver associated with toxemia of pregnancy occurs rarely, but is probably the gravest complication that can occur during pregnancy. Twenty-one cases have been recorded in the medical literature since Abercrombie’ first described the entity in 1844. The last reported case was by Pavlic and T0wnsend.s This is a 37-year-old Negro female, para 2-O-l-2, who was seen because of upper abdominal pain, nausea, and shortness of breath. Her last normal ueriod had occurred in December. 1961, and she was due in early September, 1962. The first prenatal clinic visit was made the first week in April, at which time she was found to be approximately 5 months pregnant and normotensive. She was not seen again until the first week of May, at which time her blood pressure was 190/110 and was associated with albuminuria and swelling of the lower extremities. Rauwolfia serpentina (Raudixin) 100 mg., was administered three times daily, and she was advised to report to the Polk County Hospital for definitive care. She failed to keep this appointment. On the afternoon of May 12, at 2:00 P.M., she noted a sudden onset of acute incapacitating, upper abdominal pain which radiated through to the back and was associated with nausea, weakness, and some shortness of breath. She made an effort to meet the problem for one hour at home, taking several milk of magnesia tablets without relief. She then called her local physician who saw her at home. She was doubled over with pain and unable to walk. She was given meperidine hydrochloride (Demerol) 100 mg., at this 1
time. The diagnostic impression was possible corunary occlusion, or an acute biliary colic. After approximately 2 hours, she was referred to the Polk Countv Hosnital. Examination 3 hours after the onset of pain revealed the blood pressure to be 240/150, and the patient in acute distress. Right upper quadrant pain and tenderness were noted. The fundus of the uterus was a fingerbreadth above the umbilicus. No fetal heart tones were heard. Meoeridine hvdrochloride. 100 me.. --I aminophylline //z grains, atropine l&o grab, and resernine (Seroasil) 2.5 mg. were .eiven. She . >., was placed in an oxygen ten; in se&-Fowler’s position. The electrocardiogram was normal. Approximately 4 hours after admission, the blood pressure suddenly fell to 90/60. She was placed in Trendelenburg position and dextran solution was given intravenously. Examination revealed a soft abdomen. The fetal skull could be palpated readily and exhibited a “ping-pang ball” sensation. The diagnosis of ruptured uterus was entertained. Pelvic examination revealed the cervix to be 2 cm. dilated. Small parts were felt. There was no bleeding. She was taken to the x-ray department for a flat plate of the abdomen. Before she could be explored, and while still on the x-ray table, the blood pressure was lost. In spite of transfusion by way of the femoral vein, she died. At autopsy, the peritoneal cavity contained approximately 1,500 C.C. of blood mixed with clots. The site of bleeding was a rupture in the capsule of the right lobe of the liver, thr capsule having been elevated approximately 2 cm. by a massive hematoma. The uterus was intact. Microscopic sections of the liver showed periportal necrosis. Sections of the kidney revealed thickening of Bowman’s capsule. The uterus displayed nothing remarkable other than a small fetus. The uteroplacental junction was intact. This case represents ported in the medical Radernaker,” the chain
the twenty-second reliterature. According to of events is infarction,
peripheral hypervascularization, vessel rupture, intrahepatic hemorrhage, tissue rupture, subcapsular hematoma, capsule perforation, hemoperitoneum, peritonitis, and death. The role of toxemia is evident by a pre-existing liver lesion of toxemia. Common factors noted in cases reported are multiparity (only one primigravida) , average age of 33 years in a patient with toxemia of pregnancy, and the right lobe of the liver is usually involved. Treatment is successful only in those cases which are surgically explored. The 6 survivals recorded in the literature were surgically explored with a preoperative diagnosis of rupturr of the uterus or abruptio placentae. If the diagnosis is suspected prior to death, immediat~~ surgical intervention may be lifesaving. Digital pressure on thr portal vein in thr region of the*